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N934 Advanced Principles of Anesthesia II > Peds Anesthesia Pharmacology > Flashcards

Peds Anesthesia Pharmacology Flashcards

1
Q

Pharmacology differences in peds

A
  • large Vd for water soluble meds (due to higher TBW)
  • decreased Vd for fat-soluble drugs (lower amt of fat)
  • altered and reduced protein binding (increases free fraction of meds)
  • longer half-lives (secondary to immature hepatic/renal fxn)
  • immature BBB
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2
Q

peds dosing

A

-based on per kg recommendation

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3
Q

50th percentile weight formula

A

(age x 2) + 9

less than 1 year old –> age (months)/2 + 4

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4
Q

volume of distribution peds

A
  • neonates have a proportionately higher total water content 70-75% (adult is 50-60%), reduced % of fat, reduced amounts of lean muscle mass
  • these differences result in a ECF volume of distribution proportionately higher than that of an adult
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5
Q

water soluble drugs

A
  • increased Vd related to higher total water content
  • large initial doses of water-soluble drugs are required
  • potentially delayed excretion
  • succ, bupi, many abx
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6
Q

fat soluble drugs

A
  • decreased Vd of fat soluble lugs related to decreased fat and muscle mass
  • increased DOA because there is less tissue mass into which the drug can distribute
  • thiopental, fentanyl
  • membrane permeability is HIGH in the newborn
  • by age 2 improved BBB
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7
Q

protein binding of drugs peds

A
  • reduced total serum protein concentrations
  • more of the administered drug is free in the plasma to exert clinical effect
  • lido and alfentanil
  • reduced dosing may be needed for drugs such as barbiturates and LAs
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8
Q

hepatic metabolism of drugs peds

A
  • hepatic enzymes usually convert meds from less polar state (lipid soluble) to a more polar water-soluble compound
  • this ability is reduced in neonates
  • the ability to metabolize a conjugate medication improves with age with both increased enzyme activity and increased delivery of drugs to the liver
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9
Q

renal excretion of drugs peds

A
  • renal function less effeciant than in adults
  • GFR and tubular fxn develop rapidly in first few months of life
  • aminoglycosides and cephalosporins have prolonged elimination 1/2 life
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10
Q

inhalation agents in peds

A
  • concentration of inhaled anesthetics in alveoli increase more rapidly with decreasing age
  • more rapid inhalation induction
  • excretion and recovery of inhaled anesthetics is also more rapid
  • OD occurs quickly and is leading cause of serious complications (like bradycardia and hypotension)
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11
Q

determinants of the wash-in of inhaled anesthetics

A
  • inspired concentration
  • alveolar ventilation
  • FRC
  • CO
  • solubility (wash in is inversely related to the blood solubility)
  • alveolar to venous partial pressure gradient
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12
Q

inhaled anesthetics peds reasons for increased onset

A
  • increased RR (higher minute ventilation, so faster onset)
  • decreased FRC
  • increased CO distribution to vessel-rich groups (straight to brain)
  • these factors result in rapid RISE in alveolar anesthetic concentration that rapidly equilibrates with blood concentrations
  • popular use of N2O allow for 2nd gas effect will speed induction further
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13
Q

other explanations for differences in peds for inhalation

A
  • cerebral maturation
  • age-related differences in blood-gas partition coefficients
  • state of hydration/dehydration
  • type of anesthesia circuit
  • vaporizer design
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14
Q

inhaled anesthetics peds differences from adults

A
  • faster induction + immature cardiac development = increased risk OD
  • blood pressure very sensitive to volatiles
  • MAC changes with age
  • removal of inhaled agents also rapid
  • all of them potentiate actions of NDMRs
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15
Q

Why is BP very sensitive to volatiles in kids?

A
  • lack of compensatory mechanisms
  • immature myocardium
  • reduced calcium stores
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16
Q

how does MAC change with age?

A
  • infants have higher MAC than noted in older children or adults
  • peaks around 3 months of age
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17
Q

Sevoflurane MAC neonates

A

3.2

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18
Q

Sevoflurane MAC infants

A

3.2

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19
Q

Sevoflurane MAC small children

A

2.5

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20
Q

Isoflurane MAC neonates

A

1.6

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21
Q

Isoflurane MAC infants

A

1.8

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22
Q

Isoflurane MAC small children

A

1.4

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23
Q

Desflurane MAC neonates

A

9.2

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24
Q

Desflurane MAC infants

A

10

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25
Q

Desflurane MAC small children

A

8.2

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26
Q

stage I of anesthesia

A
  • stage of analgesia or disorientation

- from beginning of induction of GA to loss of consciousness

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27
Q

stage II of anesthesia

A
  • stage of excitement or delirium
  • from loss of consciousness to onset of automatic breathing
  • eyelash reflex disappear but other reflexes remain intact and coughing, vomiting, and struggling may occur
  • respiration can be irregular with breath holding
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28
Q

stage III of anesthesia

A
  • stage of surgical anesthesia
  • from onset of automatic respiration to respiratory paralysis
  • divided into four planes
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29
Q

stage III plane I of anesthesia

A
  • from onset of automatic respiration to cessation of eyeball movements
  • eyelid reflex lost, swallowing reflex disappears, marked eyeball movement may occur
  • conjunctival reflex lost at the bottom of this plane
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30
Q

stage III plane II of anesthesia

A
  • from cessation of eyeball movements to beginning of paralysis of intercostal muscles
  • laryngeal reflex lost although inflammation of upper respiratory tract increases reflex irritability
  • corneal reflex disappears
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31
Q

stage III plane III of anesthesia

A
  • from beginning to completion of intercostal muscle paralysis
  • diaphragmatic respiration persists but there is progressive intercostal parlyasis
  • pupils dilated
  • light reflex abolished
  • laryngeal reflex can still be initiated by painful stimuli
  • desired plane for surgery when muscle relaxants were not used
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32
Q

stage III plane IV of anesthesia

A

-from complete intercostal paralysis to diaphragmatic paralysis

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33
Q

stage IV of anesthesia

A

-anesthetic overdose causing medullary paralysis and vasomotor collapse

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34
Q

Nitrous Oxide Peds

A
  • commonly used in peds to facilitate inhalation induction
  • enhances rate of uptake of inhaled anesthetic
  • also provides analgesia and amnesia during maintenance
  • oderless, insoluble
  • MAC 104%
  • contraindicated in pneumo, necrotizing enterocolitis, bowel obstruction, etc.
  • N2O 70% doubles size of a pneumo in 12 minutes
  • may contribute to PONV
35
Q

2nd gas effect

A
  • daltons law of partial pressure - sevo, oxygen, nitrous each at 33%
  • N2O diffuses faster into the blood than the other two
  • now alveoli has 50% of each sevo and oxygen
  • creates diffusion gradient for sevoflurane
36
Q

sevoflurane

A
  • agent of choice for inhalation induction
  • blood gas 0.68 or 0.65
  • least irritating to airway of inhaled anesthetics
  • dose related depression in RR and TV
  • common to begin with N2O then add sevo
  • single vital capacity breath induction
  • high temperature gas mixtures, low fresh gas flow rates <2L/min, use of CO2 absorbers containing barium hydroxide or soda lime can increase the production of compound A
37
Q

isoflurane

A
  • blood gas coefficient 1.43 (1.46)
  • slower and more pungent (major disadvantage)
  • appropriate to use in peds, especially after inhalation induction
  • potentiates NDMR to a greater extent than sevo or des
  • least costly inhalation agent
38
Q

desflurane

A
  • smallest blood gas coefficient 0.42
  • most pungent causes airway irritation (50% incidence of laryngospasm if used during induction)
  • better use is maintenance
  • use with LMA is controversial
  • emergence rapid
39
Q

propofol

A
  • highly lipophilic
  • rapid distribution from plasma to peripheral tissues
  • requires larger induction doses related to increased Vd
  • elimination 1/2 shorter
  • higher rate of plasma clearance
  • risk for infection (discard after 6 hours of opening)
40
Q

prop dose in peds

A
  • IV induction 1-3 mg/kg
  • TIVA infusion 25-200 mcg/kg/min
  • intraoperative nerve monitoring TIVA < 120-130 mcg/kg/min or else it may interfere with SSEP and MEP
41
Q

propofol MOA

A

-presumed to exert its sedative-hyponotic effects through an interaction with GABA, the principle inhibitory NT in the CNS

42
Q

propofol effects on CV system

A
  • produces decrease in systemic vascular resistance and SBP

- may produce profound hypotension in critically ill infants

43
Q

propofol effects on ventilation

A

-produces dose-dependent depression of ventilation

44
Q

ketamine

A
  • widely used in peds
  • dissociation of cerebral cortex
  • analgesic and amnestic - commonly used in burns/dressing changes
  • multiple routes and uses
  • preserves spontaneous respirations an aids to maintain and patent airway, however apnea and laryngospasm may still occur
45
Q

ketamine dosing peds

A
  • oral = 6-10 mg/kg
  • IM sedation = 2-5 mg/kg
  • IV induction = 1-2 mg/kg
  • IV pain = 0.5 mg/kg bolus; 4 mcg/kg/min infusion
  • IM induction = 5-10 mg/kg
46
Q

ketamine side effects

A
  • secretions
  • vomiting
  • hallucinations
47
Q

ketamine MOA

A
  • produces dissociative anesthesia
  • may resemble cataleptic state
  • patient’s eyes may remain open with slow nystagmus (warn parents if in OR)
48
Q

ketamine effects of CV system

A
  • effects resemble SNS stimulation
  • increased BP
  • increased pulmonary pressures
  • increased HR
  • increased CO
49
Q

ketamine efefcts of ventilation

A
  • does not produce significant respiratory depression unless given by rapid IV dose
  • does produce bronchodilation and use useful in asthmatic patients
50
Q

etomidate

A
  • not wisely used in children
  • pain on injection, myoclonus, anaphylactoid reactions, and suppression of adrenal function
  • hyponotic steroid based induction agent
51
Q

etomidate dose

A

0.2-0.3 mg/kg

52
Q

etomidate main advantage

A

CV stability in hypovolemic patients

53
Q

etomidate main disadvantage

A

adrenocortical suppression not well tolerated in critically ill children

54
Q

etomidate MOA

A

presumed to produce CNS depression via an ability to enhance the inhibitory NT GABA

55
Q

etomidate effects on CV system

A

produces minimal changes in HR and CO

56
Q

etomidate effects on ventilation

A

produces dose-dependent depression of ventilation

57
Q

opioids in peds

A
  • more potent effects in peds
  • considered to be a result of an immature BBB
  • increased sensitivity of the respiratory centers
58
Q

morphine in peds

A
  • 0.025 mg/kg IV
  • histamine release
  • hepatic conjugation reduced
  • renal clearance decreased
  • used quite a bit in peds
59
Q

fentanyl in peds

A
  • increased DOA in high doses r/t decreased fat/muscle
  • synthetic opioid agonist
  • acts at stereospecific opioid receptors in CNS
  • used to produce analgesia, and to blunt the circulatory response to direct laryngoscopy
  • OOA almost immediate when given IV
  • max analgesic and resp depressant effect may not be noted for several minutes
  • DOA 30-60 min
60
Q

fentanyl dosing

A

-IV 0.25-1 mcg/kg
-IV infusion 0.5-2 mcg/kg/hr
induction usually 1 mcg/kg

61
Q

hydromorphone

A
  • semi synthetic opioid agonist
  • derivative of morphine but 5x more potent
  • commonly administered IV and epidural
  • OOA 5 min
  • DOA 2-3 hours
  • patients with compromised renal function at risk of metabolite accumulation and associated neuroexcitation symptoms (tremor, agitation, cognitive dysfunction)
62
Q

naloxone

A
  • antagonizes opioids
  • reduces respiratory depression, N/V, pruritis, urinary retention
  • always titrate slowly
  • rapid onset
  • elimination half-life 1.5-3 hours
  • OD can lead to HTN, cardiac arrythmias, and pulmonary edema
63
Q

naloxone dose

A

-0.25-0.5 mcg/kg repeated doses until effect

max 2 mg

64
Q

midazolam doses

A
  • premedication = 0.5 mg/kg PO (onset 20 min); 0.2-0.3 mg/kg intranasal; 0.05 mg/kg IV (onset 5 min)
  • PICU sedation = 0.4-2 mcg/kg/min
65
Q

midazolam DOA

A

1-6 hours

66
Q

flumazenil

A
  • reversal for benzos
  • GABA receptor competitve antagonist
  • rapid onset 5-10 min
  • 10 mcg/kg IV
  • elim half life approximately 1 hour
67
Q

clonidine

A
  • pre-synaptic alpha agonist
  • binding decreases calcium levels thus inhibiting the release of norepi
  • oral premed 4mcg/kg (60-90 min onset)
  • can also be used as adjunct to regional
  • residual sedation postop
68
Q

precedex

A
  • 8x more specific for alpha-2-adrenergic receptor than clonidine with anxiolytic, sedative, and analgesic properties
  • sedation without respiratory depression
  • elimination 1/2 in kids approximately 2 hours
69
Q

precedex dosing

A
  • oral = 1 mcg/kg
  • intranasal = 1 mcg/kg
  • IV = 0.25-1 mcg/kg over 10-15 min
  • IV infusion = 0.2-2 mcg/kg/hr
70
Q

muscle relaxants in peds

A

-neonates have an increased sensitivity to NMBDs
-reduction in release of ACh and reduced muscle mass
fetal receptors have a greater opening time, allowing more sodium to enter the cell
-all have shorter onset due to faster circulation times
-may be difficult to monitor effects with PNS

71
Q

rocuronium dosing peds

A
  1. 6 mg/kg IV

1. 2 mg/kg IV RSI

72
Q

cisatricurium dosing peds

A

0.15 mg/kg IV

73
Q

vecuronium dosing peds

A

0.1 mg/kg IV

74
Q

glyco dosing peds

A

0.01 mg/kg IV

75
Q

neostigmine dosing peds

A

0.05 mg/kg IV

76
Q

sugammadex dosing peds

A
  • 2-4 mg.kg IV

- 16 mg/kg IV for 1.2 mg/kg roc dose

77
Q

succ in peds

A
  • infants require larger dose because of increased ECF volume of distribution
  • has fastest onset
  • recovery time similar to that of adult
  • admin with atropine 0.02 mg/kg IV/IM to prevent bradycardia due to muscarinic side effects of succ
78
Q

peds at increased risk of the following with succ admin

A
  • cardiac arrhythmias
  • hyperkalemia
  • rhabdo
  • myoglobinuria
  • masseter muscle spasm
  • MH
  • if cardiac arrest - treat hyperkalemia
79
Q

succ dosing peds

A
  • IM intubation <10kg 2 mg/kg; >10 kg 1-2 mg/kg
  • IM 4 mg/kg
  • IV 0.25-0.5 mg/kg
80
Q

ketorolac

A
  • NSAID
  • 0.5 mg/kg IV
  • elimination half-life is approx 4 hours
  • caution in impaired renal, increased risk of bleeding, impaired bone healing
  • may be reserved for children >1 year
81
Q

symptoms hypoglycemia

A
  • jitteriness
  • convulsions
  • apnea
82
Q

acute hypoglycemia management

A
  • 10% dextrose 1-2 mL/kg
  • never administer bolus of D50% due to risk of vessel necrosis and high osmolarity
  • maintenance on supplemental IV dextrose infusions
  • minimize preop fasting
83
Q

dilute D50%

A

1 mL D50% in 5 mL for 0.1 g/mL or D10%

1 mL D50% in 10 mL for 0.05 g/mL or D5%

N934 Advanced Principles of Anesthesia II (17 decks)

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